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Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.
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Artroplastia de Quadril , Artroplastia do Joelho , Idoso , Humanos , Estados Unidos , Medicare , Motivação , Assistência ao Convalescente , Alta do Paciente , Acessibilidade aos Serviços de SaúdeRESUMO
BACKGROUND: The incidence of total hip arthroplasty (THA) in the United States continues to increase due to its ability to markedly improve patients' quality of life. This study investigated and compared the perioperative and postoperative outcomes of simultaneous (SI-THA) and staged (ST-THA) bilateral THA procedures using an anterior-based muscle-sparing (ABMS) approach. METHODS: This retrospective case control study evaluated perioperative and postoperative outcomes from primary bilateral SI-THA or ST-THA (within 365 days) performed with the ABMS approach by 3 surgeons at a single institution between January 2013 and August 2020. A total of 226 patients (113 in each cohort) were matched based on age, sex, body mass index, and comorbidity score. RESULTS: Compared to the ST-THA group, the SI-THA had shorter anesthesia duration (P < .001) and shorter length of stay (P < .001), but longer length of surgery (P = .002). There was no statistical significance between groups in blood transfusion rates, discharge dispositions, emergency department visits, hospital readmissions, or postoperative complications within one year. CONCLUSIONS: The results of this study demonstrate that SI-THA and ST-THA yield comparable results using the ABMS approach. Our perioperative and postoperative results suggest low rates of complications, emergency department visits, readmissions, and high rates of patient satisfaction scores. Therefore, both SI-THA and ST-THA can be considered by experienced surgeons as treatment for advanced bilateral hip arthritis.
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Artroplastia de Quadril , Humanos , Artroplastia de Quadril/efeitos adversos , Estudos Retrospectivos , Estudos de Casos e Controles , Qualidade de Vida , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , MúsculosRESUMO
BACKGROUND: The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care. METHODS: We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores. RESULTS: A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent. CONCLUSIONS: Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.
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In the previous paper, discussing "Risk and the Future of Musculoskeletal Care," we reviewed the basic concepts of the risk corridor, implications on health care overall if we maintain a fee-for-service model, and the need for musculoskeletal specialists to begin taking on/managing risk to reinforce our presence in a "value-based care" system. This paper discusses the successes and failures of recent value-based care models and provides the framework for the paradigm of a specialist-led care model. We posit that orthopedic surgeons are the most knowledgeable physicians to manage musculoskeletal conditions, create new and innovative models, and lead value-based care to the next level.
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Doenças Musculoesqueléticas , Médicos , Humanos , Atenção à Saúde , Planos de Pagamento por Serviço Prestado , Doenças Musculoesqueléticas/cirurgiaRESUMO
BACKGROUND: The American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation. METHODS: A 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics. RESULTS: There were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%). CONCLUSION: Responding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.
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Artroplastia de Quadril , Artroplastia do Joelho , Cirurgiões , Idoso , Humanos , Estados Unidos , Medicare , Inquéritos e Questionários , Política de SaúdeRESUMO
OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Artroplastia do Joelho , Osteoartrite do Quadril , Osteoartrite do Joelho , Osteoartrite , Reumatologia , Cirurgiões , Humanos , Osteoartrite do Quadril/complicações , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/cirurgia , Dor , Estados UnidosRESUMO
BACKGROUND: A number of provisions exist within the Patient Protection and Affordable Care Act that focus on improving the delivery of health care in the United States, including quality of care. From a total joint arthroplasty perspective, the issue of quality increasingly refers to quantifying patient-reported outcome metrics (PROMs). This article describes one hospital's experience in building and maintaining an electronic PROM database for a practice of 6 board-certified orthopedic surgeons. METHODS: The surgeons advocated to and worked with the hospital to contract with a joint registry database company and hire a research assistant. They implemented a standardized process for all surgical patients to fill out patient-reported outcome questionnaires at designated intervals. RESULTS: To date, the group has collected patient-reported outcome metric data for >4500 cases. The data are frequently used in different venues at the hospital including orthopedic quality metric and research meetings. In addition, the results were used to develop an annual outcome report. The annual report is given to patients and primary care providers, and portions of it are being used in discussions with insurance carriers. CONCLUSION: Building an electronic database to collect PROMs is a group undertaking and requires a physician champion. A considerable amount of work needs to be done up front to make its introduction a success. Once established, a PROM database can provide a significant amount of information and data that can be effectively used in multiple capacities.
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Bases de Dados Factuais , Ortopedia/estatística & dados numéricos , Medidas de Resultados Relatados pelo Paciente , Sistema de Registros , Atenção à Saúde , Hospitais , Humanos , Patient Protection and Affordable Care Act , Inquéritos e Questionários , Estados UnidosRESUMO
Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m2) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m2) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach. This retrospective cohort study observes peri- and postoperative outcomes of MO and HW patients who underwent a primary, unilateral THA with the ABMS approach. Data from surgeries performed by three surgeons at a single institution was collected from January 2013 to August 2020 and analyzed using Microsoft Excel and Stata 17.0. This study compares 341 MO to 1,140 HW patients. Anaesthesia, surgery duration, and length of hospital stay was significantly lower in HW patients compared to MO. There was no difference in incidence of pulmonary embolism, periprosthetic fracture, or dislocation between the two groups. The rate of infection in MO patients (1.47%) was significantly higher than HW patients (0.14%). Preoperative patient-reported outcome measures (PROMs) show a significantly higher pain level in MO patients and a significantly lower score in functional abilities. Overall, six-week and one-year postoperative data show higher levels of pain, lower levels of functional improvement, and lower satisfaction scores in the MO group. The comorbidities of obesity are well studied; however, the implications of THA using the ABMS approach have not been studied. Our peri- and postoperative results demonstrate significant improvements in PROMs in MO patients undergoing THA. However, the incidence of deep infection was significantly higher in this group compared with HW patients.
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Background: As the population ages, total hip arthroplasty has become more common in elderly patients including patients over the age of 90 years. Efficacy in this age group has been established, though literature regarding safety of total hip arthroplasty in nonagenarians is mixed. The anterior-based muscle-sparing (ABMS) approach, which exploits the intermuscular plane between the tensor fasciae latae and the gluteus medius, has proposed benefits of fast recovery, excellent stability, and reduced bleeding and may be adventitious among elderly, more fragile patients. Methods: A total of 38 consecutive nonagenarians undergoing elective, primary total hip arthroplasty via the ABMS approach for any indication from 2013 to 2020 were identified, and information regarding operative outcomes and patient-reported outcomes was gathered from review of medical records and our institutional joint replacement outcomes database. Results: Included patients ranged from 90 to 97 years of age with the majority classified as American Society of Anesthesiologists score 2 (50%) or American Society of Anesthesiologists 3 (47.4%). The mean operative time was 74.6 minutes ± 13.6 minutes. Of all patients, 5 required a transfusion, 2 patients were readmitted within 90 days, and there were no major complications. The mean hospital length of stay was 2.8 days ± 0.8 days with 22 patients (57.9%) discharged to a skilled nursing facility. Limited patient-reported outcomes data showed statistically significant improvements in most outcomes scores at 6 months to 1 year postoperatively compared to preoperative scores. Conclusions: The ABMS approach is safe and effective in nonagenarians who may benefit from decreased amounts of bleeding and recovery times associated with the ABMS approach, which is evident from the low complication rates, relatively short hospital lengths of stay, and acceptable transfusion rates compared to previous studies.
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OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Artroplastia do Joelho , Osteoartrite , Reumatologia , Cirurgiões , Humanos , Osteoartrite/terapia , Dor , Estados UnidosRESUMO
OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Artroplastia do Joelho , Osteoartrite do Quadril , Osteoartrite do Joelho , Osteoartrite , Reumatologia , Cirurgiões , Humanos , Artroplastia do Joelho/efeitos adversos , Osteoartrite/terapia , Osteoartrite do Quadril/complicações , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/terapia , Dor , Estados UnidosRESUMO
Background: The direct anterior and posterior approaches are well-researched options in total hip arthroplasty (THA). The less-studied anterior-based muscle-sparing approach, also known as the ABLE advanced anterior approach, centers on minimizing surgical trauma and medical costs while maintaining or improving patient outcomes. Material and methods: THAs performed using the ABLE approach by 3 surgeons at a single institution between January 2013 and August 2020 were retrospectively assessed for outcomes pertaining to safety and performance intraoperatively, perioperatively, and postoperatively. Additionally, intraoperative and postoperative complications were evaluated, and patient-reported outcome measures and radiographic outcomes out to 1-year follow-up. Results: There were 6251 THAs (5433 patients) eligible for inclusion. The mean surgical time was 65 minutes, mean intraoperative blood loss was 204 mL, and the transfusion rate was 0.5%. Patients had a mean length of stay of 1.4 days. Overall, 93.4% of patients were discharged home, 1.9% visited the emergency department within 30 days, and 2.9% had an unplanned readmission to the hospital within 90 days. The overall major surgical complication rate was 1.18%, with a dislocation rate of 0.13%, a deep infection rate of 0.19%, and a postoperative periprosthetic fracture rate of 0.37%. Conclusions: The minimally invasive ABLE approach is a safe and effective surgical approach for patients undergoing THA. It can be performed efficiently and with limited complications, making it an appealing option for surgeons to utilize during this era of value-based care.
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BACKGROUND: The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system. QUESTIONS/PURPOSES: The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA. RESULTS: From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction. CONCLUSIONS: During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA. LEVEL OF EVIDENCE: Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.
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Artroplastia do Joelho/economia , Centers for Medicare and Medicaid Services, U.S./economia , Gastos em Saúde , Custos Hospitalares , Hospitais de Ensino/economia , Reembolso de Seguro de Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/instrumentação , Controle de Custos , Redução de Custos , Feminino , Humanos , Inflação , Prótese do Joelho/economia , Tempo de Internação/economia , Masculino , Massachusetts , Pessoa de Meia-Idade , Modelos Econômicos , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: The introduction of new technology has increased the hospital cost of THA. Considering the impending epidemic of hip osteoarthritis in the United States, the projections of THA prevalence, and national cost-containment initiatives, we are concerned about the decreasing economic feasibility of hospitals providing THA. QUESTIONS/PURPOSES: We compared the hospital cost, reimbursement, and profit/loss of THA over the 1990 to 2008 time period. METHODS: We reviewed the hospital accounting records of 104 patients in 1990 and 269 patients in 2008 who underwent a unilateral primary THA. Hospital revenue, hospital expenses, and hospital profit (loss) for THA were evaluated and compared in 1990, 1995, and 2008. RESULTS: From 1990 to 2008, hospital payment for primary THA increased 29% in actual dollars, whereas inflation increased 58%. Lahey Clinic converted a $3848 loss per case on Medicare fee for service, primary THA in 1990 to a $2486 profit per case in 1995 to a $2359 profit per case in 2008. This improvement was associated with a decrease in inflation-adjusted revenue from 1995 to 2008 and implementation of cost control programs that reduced hospital expenses. Reduction of length of stay and implant costs were the most important drivers of expense reduction. In addition, the managed Medicare patient subgroup reported a per case profit of only $650 in 2008. CONCLUSIONS: If hospital revenue for THA decreases to managed Medicare levels, it will be difficult to make a profit on THA. The use of technologic enhancements for THA add to the cost problem in this era of healthcare reform. Hospitals and surgeons should collaborate to deliver THA at a profit so it will be available to all patients. Government healthcare administrators and health insurance payers should provide adequate reimbursement for hospitals and surgeons to continue delivery of high-quality THAs. LEVEL OF EVIDENCE: Level III, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.
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Artroplastia de Quadril/economia , Economia Hospitalar/tendências , Custos Hospitalares , Reembolso de Seguro de Saúde/economia , Osteoartrite do Quadril/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Controle de Custos , Economia Hospitalar/estatística & dados numéricos , Tabela de Remuneração de Serviços , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Medicare , Pessoa de Meia-Idade , Osteoartrite do Quadril/cirurgia , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Total hip replacement (THR) must be managed in a more sustainable manner. More cost-effective surgical techniques and the centralization/regionalization of services are two solutions. The former requires an assessment of newer minimally invasive and muscle-sparing surgical techniques. The latter necessitates an effective volume-outcome (VO) relationship. Prior studies have failed to evaluate and control for the VO relation. OBJECTIVE: The objective of this study was to evaluate the relative cost and outcome effectiveness of two minimally invasive and one muscle-sparing techniques while evaluating and controlling for a potentially endogenous VO relation. METHODS: An all payer claims database for all THR performed in Maine in 2011 was used. The cost and outcome effectiveness of newer minimally invasive (modified Hardinge) and muscle-sparing (modified Watson-Jones) techniques were compared with the standard bearer posterior minimally invasive method. Using regression analysis, the outcomes analyzed were as follows: total costs, length of hospital stay, nursing care and home discharges, and use of physical therapy. Regression analysis was also used to evaluate and control for VO effects. RESULTS: (1) Newer muscle-sparing and minimally invasive approaches are substantially more effective; (2) irrespective of technique, higher volume surgeons are more effective; (3) technique-specific VO effects for more complex techniques exist and show substantial savings when yearly volume exceeds 30-50; and (4) the anterolateral muscle-sparing technique is accessible to the average surgeon. CONCLUSION: Reliance on newer surgical techniques and centralization/regionalization of THR services can reduce costs.
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Artroplastia de Quadril/economia , Centers for Medicare and Medicaid Services, U.S./economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Idoso , Artroplastia de Quadril/métodos , Centers for Medicare and Medicaid Services, U.S./normas , Análise Custo-Benefício , Feminino , Humanos , Revisão da Utilização de Seguros , Maine , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Análise de Regressão , Estados UnidosRESUMO
OBJECTIVES: To assess if pneumatic compression in conjunction with chemoprophylaxis is an effective way to reduce the incidence of deep vein thrombosis in orthopedic trauma patients sustaining fragility hip fractures. DESIGN: Two hundred patients admitted to the authors' institution between May 1998 and June 2002 for fractures of the hip were prospectively studied. All patients were treated operatively and received the VenaFlow calf compression device on both lower extremities immediately following surgery. Chemical prophylaxis of either aspirin (n = 67) or warfarin (n = 133) was administered in addition to mechanical compression. A noninvasive serial color flow duplex scan was performed 1 to 11 days postoperatively (mean 4.5 days) to determine the presence or absence of deep vein thrombosis. All patients were followed clinically 3 months postoperatively for a clinical evaluation of symptomatic deep vein thrombosis or pulmonary embolism. RESULTS: Overall, the incidence of deep vein thrombosis was 3.5% (7 of 200) and included only 1 proximal thrombosis (1 out of 200, or 0.5%) and no pulmonary embolism. Five of the 7 patients positive for deep vein thrombosis were in the mechanical compression and warfarin prophylaxis group and 2 were in the aspirin arm of the study. For patients with deep vein thrombosis, the average number of risk factors was 3.71, whereas patients without clots averaged 1.75 clinical risk factors (P < or = 0.05). Three patients in the warfarin group developed bleeding complications (1 with a gastrointestinal bleed and 2 with minor bleeding not at the operative site). No evidence of a symptomatic deep vein thrombosis or pulmonary embolism was reported within a 3-month period following hospitalization. CONCLUSIONS: Our findings suggest mechanical compression with the VenaFlow calf compression device in conjunction with chemoprophylaxis is an effective means of reducing thromboembolic disease in this high-risk population.
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Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Fraturas do Quadril/complicações , Fraturas do Quadril/cirurgia , Embolia Pulmonar/prevenção & controle , Trombose Venosa/prevenção & controle , Varfarina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril , Feminino , Fraturas do Colo Femoral/complicações , Fraturas do Colo Femoral/cirurgia , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco , Ultrassonografia Doppler Dupla , Trombose Venosa/diagnóstico por imagemRESUMO
BACKGROUND: The Optetrak PS (Exactech, Inc., Gainesville, FL) has been a well-functioning posterior stabilized knee replacement since its introduction in 1995. In 2009, the Optetrak Logic incorporated modifications to the anterior face of the tibial post and the corresponding anterior articulating surface of the femoral component to reduce edge loading on the polyethylene post. In this study, we provide the rationale for the design change and compare the damage on retrieved tibial components of both designs to demonstrate the effectiveness of the design modifications in decreasing post damage. METHODS: We integrated retrieval findings of tibial post damage with finite element analysis to redesign the anterior tibial post-femoral box articulation. We then used subsequent retrieval analysis on a 3:1 matched sample of 60 PS and 20 Logic inserts to examine the impact of the design change on polyethylene damage. RESULTS: Polyethylene stresses were markedly reduced when rounded contact geometries were incorporated. The comparison of the new and old designs using retrieval analysis demonstrated that the redesign led to reduction in surface damage and deformation on the tibial post. CONCLUSIONS: This study shows the use of a design cycle by which a problem is identified through retrieval analysis, analytical tools are used to suggest design solutions, and then retrieval analysis is applied again on the new design to confirm improved performance. CLINICAL RELEVANCE: Anterior post damage has been markedly reduced through the introduction of design changes to the post-box geometry.